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• Postoperative osteopathic manipulative management of median sternotomy patients

JERRY L. DICKEY, DO

More than 250,000 patients geons are also using this incision in pulmo- yearly undergo coronary bypass graft sur- nary procedures. Attendant to the more wide- gery accomplished via the median ster- spread use of this operative approach has been notomy incision, an approach that has an increase in the number of patients who are been gaining widespread acceptance. This being seen with structural complaints postop- surgical approach has been associated eratively. Current medical literature docu- with a growing number of patients with ments the more dramatic consequences but structural complaints. This article de- fails to relate more subtle changes in chest scribes a postoperative treatment proto- cage mechanics resulting from the use of this col for improving healing and reducing approach. musculoskeletal disability associated with The purpose of this article is to suggest an such cardiac procedures and presents a osteopathic treatment regimen that addresses logical sequence of treatment graded to these alterations of and physiology. the patients changing condition and stage of healing. The author challenges the os- Incidence teopathic medical profession to meet the Although it is difficult to pinpoint the precise opportunity that exists to educate patients number of surgical procedures in which the and physicians about the benefits of os- median sternotomy approach is used, the num- teopathic healthcare. ber in the United States probably exceeds 250,000 per year. The sharp increase in coro- There has been increasing acceptance of the nary bypass graft procedures for the treatment use of the median sternotomy approach in in- of coronary insufficiency contributes the larg- trathoracic surgical procedures. It is the pre- est single group of patients undergoing me- ferred approach for cardiac surgical proce- dian sternotomy. From 1979 to 1982, there was dures, and a growing number of thoracic sur- a 48% increase in the number of coronary by- pass graft procedures 2; in 1983, there were a reported 191,000 such procedures performed in the United States. 3 The increasing use of Dr Dickey is chairman of the department of manipulat- coronary bypass graft , in addition to ive medicine, Ibxas College of Osteopathic Medicine, other open and pulmonary procedures, Fort Worth. He wrote this thesis as part of the require- ment for Fellowship certification in the American Acad- could push the number of median sternotomies emy of Osteopathy. to more than 400,000 per year in the near fu- ture. Such numbers behoove the osteopathic Reprint requests to Jerry L. Dickey, DO, chairman, de- medical profession to develop treatment ap- partment of manipulative medicine, lexas College of Os- proaches that will address the postoperative teopathic Medicine, 3500 Camp Bowie Blvd, Fort Worth, structural needs of this enlarging population. TX 76107-2690.

JAOA • Vol 89 • No 10 • October 1989 • 1309 Clinical practice • Dickey Common operative approach Treatment plan In the common operative technique for median All of the complications reported in the litera- sternotomy, the surgeon divides the with ture are readily observed in the immediate post- a rectilinear median incision from the supra- operative period. The literature fails to men- sternal notch to below the and tion the structural and functional changes in uses diathermy to separate the subcutaneous chest cage mechanics that do not become evi- layers and achieve hemostasis. The surgeon dent until weeks, or even months, after sur- then divides the by use of an electric gery. Of interest to the osteopathic physician saw and covers the exposed edges with are hypomobility and somatic dysfunction of bone wax.4 Next, the operator retracts the ster- the and cage, disruption num by use of an Ankeney retractor, with the of fascial patterns through the mediastinum, upper end placed at the level of the second rib. pain (thoracic), and limited or distorted For cardiac procedures, the pericardial sac is dysfunction of the diaphragm. opened to expose the heart. The treatment plan proposed here addresses Following the surgical procedure, some sur- these potential sequelae as they arise, start- geons close the pericardium, while others in- ing with the preoperative phase and continu- completely close the pericardium to allow bet- ing through the immediate postoperative pe- ter drainage. The cut sternal margins are ap- riod to approximately 6 months postopera- proximated with four to six stainless steel fig- tively. ure-of-eight sutures. The superficial tissues usu- ally are closed with cutaneous absorbable su- Preoperative treatment plan tures. Pericardial, substernal, and pleural Ideally, the osteopathic physician should as- drainage tubes exit the chest below the xiphoid sess the patients function preopera- process. tively, noting and recording symmetry or asym- metry and patterns, including depth Common sequelae of respiration as a function of diaphragmatic The common postoperative sequelae reported excursion. Somatic dysfunction of the cervical in the literature include wound dehiscence, sub- vertebrae should be mobilized in preparation sternal and pericardial infection, nonunion of for intubation. Somatic dysfunction of the tho- the sternum, pericardial constriction, phrenic racic vertebrae and should be treated to nerve injuries, rib fractures, and brachial optimize tidal volume, and lumbar restriction plexus injuries. The last two sequelae are of should be improved to aid the excursion of the particular interest because they are probably diaphragm. Unfortunately, all too often the os- related. teopathic physician does not see the patient Studies have placed the incidence of bra- until after surgery, and so has not had the op- chial plexus injuries as high as 23.5%. 5 Van- portunity to assess preoperative function. der Salm and associates5 performed median One should attempt to impress on the sur- sternotomies on ten cadavers using the com- geon the importance of anatomically accurate mon surgical approach previously described. approximation of the sawed sternal halves. Seven of the ten cadavers sustained first rib The function of the of Louis is fractures, with the fractured ends of the ribs vital to the proper function of the upper rib often impaling the lower trunks of the brachial cage. It is not uncommon for surgeons to ac- plexus. These investigators operated on an ad- cept discrepancies of 0.25 inch when suturing ditional ten cadavers in which they placed the the sternal halves. Such malalignment may upper end of the Ankeney retractor at the level well adversely affect sternal and rib cage of the fourth rib instead of at the level of the mechanics. second rib, and they observed no rib fractures.5 Such fractures usually are occult and are de- Early postoperative treatment plan tected only by radioactive isotope bone scan- Usually, it is not until the postoperative pe- ning; many go unrecognized. riod that the osteopathic physician sees the pa-

1310 • JAOA • Vol 89 • No 10 • October 1989 Clinical practice • Dickey Figure 1. Testing fascial patterns of the chest.

tient who has undergone median sternotomy. The upper four ribs usually are more se- Ideally, one should begin assessment and treat- verely injured as a result of the placement of ment as soon as possible after the patients dis- the Ankeney retractor. Upper ribs normally missal from surgery and before there has been have less mobility than lower ribs owing to time for the sequelae associated with healing their firmer attachment, posteriorly to the ver- to develop. Certainly, a month postsurgery is tebrae and anteriorly to the sternum. The wide not too soon to begin treatment. retraction necessary for the median sterno- The proposed treatment plan is based on the tomy approach places more mechanical force assumption that functional healing of the ster- on the upper than on the lower ribs. Intercos- num is incomplete. Modifications in type of tal muscle contraction is usually present, as treatment and duration are made as healing is dysfunction and focal contraction of the dia- continues. Since the majority of median ster- phragm. notomy patients will have undergone coronary With the patient in the supine position, the bypass graft surgery, it is likely that this pa- physician evaluates the patterns of injury to tient population is in the sixth and seventh the chest and sternum by placing one decades of life. Such patients likely will have between the (Fig 1) while placing and chronic musculoskeletal problems and os- resting the other hand on the skin in the teoarthritis that predate the surgical insult. midline of the sternum. Turning each hand in- Chronic obstructive pulmonary disease and dependently in a clockwise, then counterclock- other chronic disease states may further com- wise direction, will reveal the tissue prefer- plicate the assessment. ence pattern. These findings should be re- The initial step is to repeat the evaluation corded because they usually change through previously described here for the preoperative the course of treatment. assessment. Even if presurgical data are not Treatment consists of gently encouraging available, postsurgical evaluation of breath- both anterior and posterior tissue preference ing patterns and chest cage symmetry is help- patterns and holding them until tissue tension ful. The physician should lightly palpate the relaxes. The physician should monitor chang- sternum to assess functional healing and the ing tension states during the treatment phase costochondral junctions to determine the de- and make modifications to maximize tissue re- gree of trauma sustained. laxation. This fascial approach should be con-

Clinical practice • Dickey JAOA • Vol 89 • No 10 • October 1989 • 1311 tinued on a weekly basis until the fascial pat- pump handle rib motion, the maximum excur- terns cease to change or are resolved. sion is at the anterior end. The ideal pattern for the of the chest With the patient in the supine position, the would be to have equal excursion in both clock- physician places flattened palms over the pec- wise and counterclockwise rotations of the tis- toral regions (Fig 2), directing alternating but sues; however, according to Zink and associ- equal pressure posteriorly through the ante- ates,6 most individuals have a preference pat- rior aspect of the chest wall into the second tern in these tissues. Treatment of these fas- through sixth ribs. Asymmetry of compress- cial patterns will commonly release recent ibility indicates the need for more specific mo- strains and reveal older tissue preference pat- tion testing of each rib. A similar test is used terns. Treatment may release strains and re- for mid and lower ribs: The physician places turn the tissue to the ideal state. Most com- flattened palms against the rib cage at the mid- monly, changing tissue patterns will assume axillary line and applies alternating compres- an older strain pattern and will become static. sion medially and records any asymmetry Next, the physician should cautiously ap- detected. proach the rib cage. One should refrain from lb test the ribs dynamically, the physician high-velocity techniques because occult rib frac- places a either on or between the ribs tures are all too common in patients who have while using the other hand to monitor the had median sternotomy. Function of the rib contralateral ribs, again with the patient su- cage should be assessed both statically and dy- pine (Fig 3). The physician should note sym- namically. Because upper ribs predominate in metry of paired rib motion during the respira-

Figure 2. Evaluating chest cage compliance. Figure 3. Evaluating rib motion.

1312 • JAOA • Vol 89 • No 10 • October 1989 Clinical practice • Dickey Figure 4. Indirect procedure for rib dysfunction, front view. tory cycle, or in the case of asymmetry, record the phase of the respiratory cycle in which the asymmetry appeared. With practice, the phy- sician will be able to monitor three or four ribs on both sides simultaneously. Patients who have had median sternotomy almost always need treatment of multiple ar- eas of somatic dysfunction in the rib cage. Treat- ment need not be complicated, but it should be atraumatic. The use of indirect 7 rib tech- nique is particularly valuable because it al- lows the simultaneous treatment of intercos- tal muscle spasm and rib articulations. A technique approach used by Sutherland and outlined by Kimberly 8 is appropriate for this initial phase of treatment (Figs 4 and 5). The patient sits on one side of the table, and the physician sits on the opposite side. The phy- sician contacts the lesioned rib with the index and middle of one hand along the ante- rior end of the rib, while positioning the index and middle fingers of the other hand along the posterior angle of the rib. The physician places the of both end to end on the rib at the midaxillary line. The patient straight- ens the spine and leans sideways toward the physician until making firm contact. The pa- tient is instructed to rotate his or her toward the side opposite of contact until the physician feels that the palpated rib head is slightly free from its demifacets. On instruction, the patient partially inhales and then exhales to allow the physician to de- termine which respiratory phase permits the greatest freedom from tension. Again, as in- structed, the patient assumes the respiratory phase of maximum freedom and holds his or her breath for as long as possible. The physi- cian adjusts his or her contacts to maintain maximum freedom from tension, and holds this position until the rib is free of restriction. Several breaths may be necessary to attain com- plete freedom of motion. To be effective, this treatment approach may need to be repeated

Figure 5. Indirect procedure for rib dysfunction, rear view.

Clinical practice • Dickey JAOA • Vol 89 • No 10 • October 1989 • 1313 Figure 6. Evaluating and treating fas- cial restrictions of the .

for several weekly visits. It also tends to re- Somatic dysfunction of the cervical and tho- store normal sympathetic function through the racic vertebrae is almost always present in the affected thoracic segments. early postoperative period. Thoracic somatic The thoracic lateral chain ganglions of the dysfunction is probably due to a combination sympathetic division of the autonomic nerv- of direct trauma and somatosomatic reflexes. ous system lie on the anterior surface of the Somatic dysfunction of the rib heads. Wide anterior retraction of the ster- is probably related to positioning for intuba- num will cause the costotransverse articula- tion and reflexes through the phrenic nerve. tion to act as a fulcrum to lever the rib heads Although it is acceptable at this early stage anteriorly from their articulations with the de- to use direct-action high-velocity techniques mifacets. Such action may cause injury to the for the cervical vertebrae, such techniques capsule of the rib head and supporting liga- should be avoided in the thoracic vertebrae. ments and create compression of the sympa- Initially, it is preferable to use muscle energy9 thetic ganglions lying on the rib head. or indirect procedures for thoracic somatic dys- With healing, scar tissue may entrap the function. ganglions or create hypomobility of the af- In the immediate postoperative period, spe- fected rib. Because rhythmic motion due to res- cial attention should be given to the dia- piration is the natural state for the thoracic phragm. Dysfunction will be obvious as dis- sympathetic ganglions, the hypomobility of the torted breathing patterns and decreased depth ribs that develops with healing must repre- of excursion. In addition to traction injury of sent a distortion in normal physiology, thus the diaphragm due to wide retraction of the altering function of the thoracic sympathetic divided sternum and the lower six ribs, there ganglions. may be disruptions of the diaphragms attach- Disturbed thoracic sympathetic function ments to the xiphoid process of the sternum. may be manifested as a vasomotor instability The patient may be unable to take a deep in- and increased sweat gland activity of the head, spiration due to pain in the diaphragm. Gen- , thoracic region, or upper extremities. tle palpation beneath the inferior border of the Commonly, patients complain of vague rib cage will reveal contraction of narrow slips pain that does not correspond to dermatome of fibers of the diaphragm (Fig 6). reference patterns. Many times these pain pat- At this stage, treatment consists of the phy- terns are referable to sympathetic vasomotor sicians gently inserting his or her or disturbances affecting the upper extremities. fingertips below the while the

1314 • JAOA • Vol 89 • No 10 • October 1989 Clinical practice • Dickey patient maintains full . The physi- have undergone median sternotomy. Such trig- cian applies and maintains light pressure to ger points are most likely to be located in the the contracted fibers while the patient inhales pectoral, the trapezius, and latissimus dorsi fully. A Valsalva maneuver by the patient also muscles. By using the Fluori-Methane spray- will help to stretch the involved fibers. As the and-stretch techniques of Travell and Si- patient exhales, the physicians fingertips fol- mons, 10 the physician can eliminate the ma- low the diaphragm upward and maintain this jority of these trigger points. Failure to address position as the patient inhales again and per- these points can lead to needless pain and dis- forms another Valsalva maneuver. The physi- ability. Resistant trigger points usually re- cian maintains pressure through several res- spond to injection of a local anesthetic agent, piratory cycles until observing release of ten- followed by stretching of the involved muscle sion. It will be necessary to repeat this ap- fibers. proach weekly until stubborn areas of contrac- Because the treatment plan proposed so far tion are released. For treatment of somatic dys- cannot be completed at the patients first visit function of the , either mus- or at any single visit during the treatment se- cle energy or indirect techniques may be used quence, the physician should treat the areas to release the origin of the diaphragm. of greatest need first, and then repeat treat- Early in the treatment sequence, specially ment at subsequent visits. In the time that re- trained physicians should evaluate the pri- mains during any given visit, the physician mary respiratory mechanism. The author has can evaluate and treat areas with secondary found through experience that the will need. One should grade treatment to patient demonstrate restrictions more often than the age, condition, and stage of healing. For the cranium, possibly as a result of disruption of first 8 to 10 weeks after surgery or until there fascial continuity, disturbed respiratory pat- has been functional union of the sternum and terns, or positioning or transfer maneuvers dur- any possible rib fractures, the physician should ing surgery (either singly or in combination). avoid using high-velocity techniques except for The disturbance of respiratory patterns is prob- the cervical vertebrae. ably the most likely cause. Spasm and direct injury to the diaphragm alter the tension on Late postoperative treatment plan its lumbar attachments. Tension is usually The use of high-velocity techniques has increas- noted in the lumbosacral region in the early ing value after the third postoperative month. stages of treatment, resulting in inhibition of The wide retraction of the median sternotomy motion of the sacral base; however, a common places significant forces on the costotransverse pattern of restriction has not been observed. and costovertebral , with injury to their Some patients who have no evidence of bra- capsules and supporting ligaments. This in- chial plexus injury complain of achy pain in jury appears to be worse in older patients, bar- the upper extremities, often accompanied by rel-chested patients, and patients with fixed mild swelling in the posterior axillary fold. rib cages. Hypermobility of costotransverse This combination indicates a lymphatic drain- and on the initial evalu- age problem, in which case the physician ation of the rib cage motion should lead the should assess the tissue preference patterns examiner to suspect this type of injury. By the of the upper arm and the independ- third month of healing, scar formation may ently. The physician should combine and hold lead to progressive hypomobility of these these tissue preference patterns with slight com- joints, at which time the use of thrusting tech- pression through the and un- niques achieves better results. til he or she perceives the tension relaxing. Problems with lymphatic drainage of the dia- This maneuver may have to be repeated at sub- phragm, rib cage, and upper extremity are sequent visits to provide complete relief. likely to be of concern earlier in the postop- One should anticipate the presence of myofas- erative course. However, by the third or fourth cial trigger points, formed as a result of the postoperative month, there may be evidence mechanical tissue trauma combined with hy- of faulty lymphatic drainage in the head and pothermia during surgery, in patients who neck. Persistent puffiness in the lower neck

Clinical practice • Dickey JAOA • Vol 89 • No 10 • October 1989 • 1319 style is to maintain a low-fat diet, to resume ambulation progressively, and to cease smok- ing. There is at least a theoretic basis for the use of antioxidants, which should be given con- sideration. The lowered oxygen tension of sur- gically traumatized tissues favors the forma- tion of scar tissue over normal tissue. The daily administration of 1000 units of mixed to- copherol vitamin E for 6 months may be benefi- cial. The use of a multivitamin B complex is also advised. Because 30c7c of the population will have a rise in blood pressure in response to 1 g of vitamin E, blood pressure should be monitored frequently. If blood pressure does become elevated, the dose of vitamin E is re- duced to 300 to 400 units, supplemented with 50 to 100 p.g of selenium, which has a syner- gistic effect." Because the most difficult obstacle is the maintenance of upper thoracic vertebral and rib mobility during healing, the patient should be instructed in the home use of an exercise bar. Such bars are available at sporting goods stores, or they can be fabricated from parts ob- tained from any hardware store. The bar should be placed high enough in a doorway to enable the patient to suspend his or her body Figure 7. Treating lascial restrictions of the thoracic weight supported by the twice daily for inlet. 30 seconds. The traction thus applied through the anterior and posterior shoulder muscles and supraclavicular fossae with achy pain in and their attachment to the upper ribs will the neck should alert the physician of such lym- aid mobilization. phatic drainage problems. The physician One patient has reported that while he was should treat somatic dysfunction of the first performing this exercise, he felt a tearing sen- four thoracic vertebrae and their ribs, clav- sation behind the sternum and was immedi- icles, and sternum. It is possible to stretch the ately able to take a deeper breath. He undoubt- of the lower cervical vertebrae and tho- edly had provoked a breakdown of retroster- racic inlet by placing the patient in the sitting nal adhesions. His experience gives some in- position, with the head bent forward (Fig 7 ). dication of the effects of this exercise on all The physician places his or her thumbs deeply tissues of the upper region of the body. Some into the supraclavicular fossae while the pa- of my patients have been voluntarily continu- tient exhales and bends his or her head and ing this exercise for 3 or more years because neck farther forward. On instruction, the pa- of its benefits. Patients should begin such ex- tient then takes a deep breath, sits up straight, ercises at the third postoperative month and and backward bends the head and neck at the continue them for as long as they perceive height of inspiration. This technique is in- benefit. One unanticipated benefit of median tended to lift the anterior cervical fascia. sternotomy should be mentioned. As previ- ously stated, the acute trauma to the thoracic Adjunctive treatment vertebrae and rib cage renders the thoracic On surgical dismissal, the only advice the pa- cage hypermobile for 3 to 4 months. Gradu- tient receives regarding nutrition and life- ally, by the seventh postoperative month, the

1320 • JAOA • Vol 89 • No 10 • October 1989 Clinical practice • Dickey thoracic cage becomes hypomobile as the scar resolved except for some residual pain along the retracts. This "window of opportunity" allows xiphoid process. The same fascial pattern was evi- definitive correction of somatic dysfunction of dent at the sternum but was resolving, and the the thoracic vertebrae and rib cage that may right arm was beginning to show some signs of have proved refractory to treatment preopera- edema. He had increasing tension in the right crura of the diaphragm. Treatment was aimed at unwind- tively. Longstanding and chronic somatic dys- ing fascial patterns in the right arm, , and function of the thoracic vertebrae and rib cage shoulder region as well as being directed at the may yield to treatment during this interval. sternal fascial pattern and to the diaphragm to stretch restricted and scarred regions. Report of case Approximately 2 months postoperatively, the pa- A 68-year-old male osteopathic physician under- tient began to show signs of trigger points with went a quadruple coronary bypass graft procedure pain radiating into the arms and into the neck. It via a median sternotomy approach. On the first is uncertain whether this trigger phenomena had visit about 3 weeks postoperatively, his chief com- been present since the surgical insult or had been plaint was sternal, upper thoracic, and cervical the result of increasing activity in the postoper- pain. He had a 60-pack per year smoking history tive period. Pectoral and supraspinatus trigger and a 20-year history of gouty arthritis. points were elicited and treated with spray-and- Neuromusculoskeletal examination revealed ob- stretch technique. Articulatory treatment, consist- vious increase in thoracic kyphosis as a result of ing of moving joints through their range of mo- pain on standing erect; chronic rib restrictions of tion, was instituted in the thoracic and lumbar re- the mid and upper rib cage, extending from T-4 to gions of the spine. T-8, secondary to old rib fractures; gouty arthritis The patient continued to improve slowly on in the cervical, thoracic, and lumbar spine; and weekly visits. At each visit, he expressed new symp- chronically shallow respiratory excursion. Incom- toms, which were readily relieved by addressing plete healing of the median sternotomy was evi- sternal, thoracic, and cervical areas of somatic dys- dent with crepitus to slight compression of the ster- function. By the second month, the patient had pain nal margins. The fascias and tissues overlying the radiating into the anterior aspect of the neck and sternum had a pronounced counterclockwise pref- , which was feared to be an anginal variant. erence pattern. The patient had pain on moderate Continuing work on trigger points in the trapezius , and he had multiple wound drainage and pectoral regions resolved this pain pattern. In sites in the subxiphoid region. Although these drain- the second month, high-velocity procedures were age exit wounds were dry and healing well, they directed to the cervical and lumbar regions of the indicate the invasion of the diaphragm necessary spine. Increasing manipulative activity was di- to drain both pleural cavities and the mediastinum. rected toward springing and articulatory treat- Treatment was started by the use of indirect fas- ments for the restricted rib cage, and efforts were cial techniques directed to the sternum and poste- continued to stretch the forming scar tissue in the rior region of the . Indirect technique was diaphragm. used to mobilize restriction in the cervical, thoracic, By the end of the second month, more rapid pro- and lumbar regions of the spine and the sacrum. gress was being made and the patient began a bi- The patient was placed on a daily regimen of anti- weekly treatment schedule. Efforts were now oxidant therapy consisting of 400 units of vitamin aimed more toward the thoracic region of the spine E, in mixed tocopherol form, supplemented by 50 and ribs than they had been previously. The right to 100 lig of selenium. This patient had previously crura of the diaphragm continued to be restricted had an adverse reaction—an elevation in resting in its excursion, and the rib cage began showing blood pressure—to dosages of vitamin E in excess increasing hypomobility. By the middle of the third of 1000 units per day. postoperative month, muscle energy procedures The patient was seen weekly over the next 2 were started for somatic dysfunction of the rib cage months. At the second visit, all rib heads were ar- and thoracic region of the spine. ticulated to assess mobility and possible soft tis- Progress continued, and the patient began on a sue damage to the articulations themselves. Indi- monthly treatment schedule by the beginning of rect treatment was again directed to the sternal the fourth postoperative month. At this time, the and cervical fascias, as well as to the upper tho- patient had slight cervical pain on arising, which racic and midthoracic regions of the spine, the sa- subsided spontaneously with light activity. The pa- crum, and rib cage. tient remarked that this was typical of his long- By the third visit, the patients sternal pain had time gouty arthritis. Although I continued to fo-

Clinical practice • Dickey JAOA • Vol 89 • No 10 • October 1989 • 1321 cus treatment on restricted rib cage mechanics, reso- sternotomy approach. The treatment plan ad- lution of the diaphragmatic pattern was beginning dresses such potential sequelae of this surgi- to be evident. By this time, the fascial preference cal approach as hypomobility and somatic dys- pattern of the sternal region was greatly dimin- function of the thoracic region of the spine and ished, and there was no evidence of edema in the rib cage, disruption of fascial patterns through cervical or supraclavicular regions or upper ex- the mediastinum, back pain, and limited or tremities. By the end of the fourth postoperative month, distorted dysfunction of the diaphragm. I began judicious use of high-velocity/low-ampli- tude procedures directed to the thoracic region of 1.Johnson MD, Michael R: Median sternotomy for resection the spine and the rib cage. The patient had mini- of pulmonary metastases. J Thorac Cardiovasc Surg mal symptoms and was sleeping soundly through 1983;85:516-522. the night, whereas he had had a history of awak- 2. Rimm AA: Trends in cardiac surgery in the United States. N ening at 4 or 5 AM for a number of years because Engl J Med 1985;213:119. of his gouty arthritis. The patient was now sleep- 3. Detailed diagnoses and surgical procedures for patients dis- ing routinely until 7 AM. Somatic dysfunction of charged from short-stay hospitals, 1983. National Health Sur- the thoracic region of the spine and rib cage, pre- vey, series 13, No. 82, March 1985, p 165. viously refractory to high-velocity force, was eas- 4. Harjala A, Jarvinana A: Postoperative median sternotomy dehiscence. Scand J Thorac Cardiovasc Surg 1983;17:277-281. ily mobilized at this time. (The preexisting gouty 5. Vander Salm TJ, Cereda JM, Cutter BS: arthritis had always been a deterring factor in the injury following median sternotomy. J Thorac Cardiovasc Surg use of high-velocity manipulation in this patient.) 1980;80:447. The hypermobility of costal articulations was be- 6. Zink GJ, Lawson WB: An osteopathic structural examina- ginning to be reversed at this stage, and every ef- tion and functional interpretation of the soma. Osteopathic An- fort was made to maintain proper anatomic rela- nals 1979;7:12-19. tionships and physiologic function during the late 7. Project on Osteopathic Principles Education: Glossary of os- stages of scar formation. teopathic terminology. JAOA 1982;552-567. By the fifth postoperative month, the patient was 8. Kimberly PE (ed): Outline of Osteopathic Manipulative Pro- cedures. Kirksville, Mo, Kirksville College of Osteopathic Medi- asymptomatic. It was evident that scar tissue was cine, 1980, p 132. retracting because active mobilization of thoracic 9. Mitchell FL Jr, Moran PS, Pruzzo NA: An Evaluation Treat- and rib somatic dysfunction suddenly became more ment Manual of Osteopathic Manipulative Procedure, ed 2. Val- difficult. In addition to the use of direct technique, ley Park, Mo, Fall 1973. the use of the home exercise bar was instituted. 10.Travell JF, Simons DG: Myofascial Pain and Dysfunction: The patient derived so much benefit from depend- The Trigger Point Manual. Baltimore, William Wilkins, 1983, ent weight hanging from this bar at home that he p 63. still uses this exercise periodically as an aid to main- 11. Synergistic relationship of selenium and vitamin E, Medi- note. JAOA 1985;85:85:350, 351. taining proper function and mobility of the tho- racic vertebrae of the spine and rib cage and asso- ciated fascial structures. Since the sixth postoperative month, the patient, at his own request, has continued to receive treat- ment on a near monthly basis. The patient could have been dismissed from regular care any time after the sixth postoperative month, but he feels that the periodic benefits of osteopathic manipu- lative treatment, in terms of both subjective and objective functioning parameters, justify maintain- ing a regular treatment schedule. Most patients are dismissed from regular care sometime between the sixth and seventh postoperative month and ap- pear to have no long-term sequelae.

Conclusion The osteopathic manipulative treatment pro- tocol described here may benefit a segment of the growing number of patients who are un- dergoing surgical procedures via the median

1322 • JAOA • Vol 89 • No 10 • October 1989 Clinical practice • Dickey